Even if we don't tally them in the super-duper official stats, why wouldn't the CDC allow doctors to submit clinical diagnoses of COVID19? You'd figure xray or CT scan of bilateral interstitial pneumonia plus doctor's judgment would be good enough right now.

Sidesteps the whole test kit issue.

k2aggie07 said:

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Even if we don't tally them in the super-duper official stats, why wouldn't the CDC allow doctors to submit clinical diagnoses of COVID19? You'd figure xray or CT scan of bilateral interstitial pneumonia plus doctor's judgment would be good enough right now.

Sidesteps the whole test kit issue.

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Sounds reasonable to me, especially since doctors are making treatment decisions on that.

The cynic in me says our leadership doesn't do that because they don't want to have the ridiculously sharp spike it would cause in the case numbers to incite more public panic.

But, I agree, it seems that if they're basing treatment plans off clinical diagnosis, then there should at least be a statistical category for clinical diagnosis maintained in parallel with the "test positive" cases.

I'm beginning to think that low numbers are strategic anyway.

Maybe you could provide a link to the discussion/analysis you are basing your CDC criticism on?

Is the theory that the CDC is doing Trump's bidding to cover up things? Really?

No idea where to link to, and it isn't really a criticism.

All the stats you're seeing now are confirmed, up til March 14 FDAwas requiring all confirmations to come from the CDC. Now they're allowing confirmations to come from local public health labs.

But then we have a supposed lack of testing capacity. CT scan is not new, and at least for a time China (citing lack of testing capacity) allowed clinical diagnosis of COVID19 to be counted, based on CT scan or other doctor's analysis. That's the huge spike you see in the data on Feb 12.

If testing is making us so blind, track clinical diagnosis alongside presumptive positives. Easy enough.

I didn't say anything about President Trump. I do think there's a role in government right now to maintain public morale and prevent panic, and limiting numbers in a plausible way does that nicely.

Can't run patients through the Radiology Dept for CT or x-ray. The amount of time to clean after is prohibitive.

The Coronavirus spike is occurring at the same time as other flu-like illnesses are edit: occuring, generally speaking. If we are going to try to get real data as to what does and doesn't work with the (remember when we were calling it) Novel Coronavirus, it really helps to make sure that you are not confounding multiple diseases. If a patient were mislabeled as having Coronavirus when in fact they didn't, that wouldn't be good.

k2aggie07 said:

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No idea where to link to, and it isn't really a criticism.

All the stats you're seeing now are confirmed, up til March 14 FDAwas requiring all confirmations to come from the CDC. Now they're allowing confirmations to come from local public health labs.

But then we have a supposed lack of testing capacity. CT scan is not new, and at least for a time China (citing lack of testing capacity) allowed clinical diagnosis of COVID19 to be counted, based on CT scan or other doctor's analysis. That's the huge spike you see in the data on Feb 12.

If testing is making us so blind, track clinical diagnosis alongside presumptive positives. Easy enough.

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I don't think a CT scan is in any way sensitive/specific enough to warrant a precise diagnosis for COVID19, or any other ILI (influenza like illness). That China allowed that for a time is not particularly compelling; they either (a) allowed it so that they could show more recoveries (vis a vis all ILI cases) or (b) another purpose such as rapid identification of potential quarantine-needed suspected patients.

The CDC didn't just cite a lack of testing capacity, it was a real thing.

False: Flu results have been declining for over a month now.

We are not in the peak, but we are still seeing flu. The Coronavirus task force physician Dr. Birx made mention of this.
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Kool said:

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We are not in the peak, but we are still seeing flu. The Coronavirus task force physician Dr. Birx made mention of this.

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I don't think you have looked at the CDC chart or comprehended my post. Flu diagnoses have been declining for over a month. It is still being seen. Have a nice day....

Agree. My wording was poor. Changed spiking to occurring. Have an even nicer day.

Quote:

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I don't think a CT scan is in any way sensitive/specific enough to warrant a precise diagnosis for COVID19, or any other ILI (influenza like illness). That China allowed that for a time is not particularly compelling; they either (a) allowed it so that they could show more recoveries (vis a vis all ILI cases) or (b) another purpose such as rapid identification of potential quarantine-needed suspected patients.

The CDC didn't just cite a lack of testing capacity, it was a real thing.

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You don't only use the CT scan. Doctors diagnose patients with diseases all the time without a lab confirmed test. I'm suggesting allow a clinical diagnosis, and x-ray / CT would be a part of that criteria.

As far as I know (and I am not a doc so this could be wrong) there aren't that many diseases that present with fever, dry cough, and bilateral interstitial pneumonia. And generally pneumonia arising from the flu is more likely to be bacterial, isn't it?

China allowed it in their stats due to testing capacity constraints (just like we're having here). The WHO team noted that they were doing CT scans extremely rapidly because they were using them for screening / diagnostic purposes.

They're still working on it, using AI to evaluate the image.
https://www.bioworld.com/articles/433530-china-uses-ai-in-medical-imaging-to-speed-up-covid-19-diagnosis

I'm not saying muddy the official confirmed numbers with clinical diagnoses. I'm saying, allow a less strict method of measurement as a broader, faster method of gathering data for local public health officials. Just like we do with the rapid test for the flu vs clinical lab test for the flu.

I know the testing limits are real. I'm saying, since they're real, and since they're directly impacting our ability to handle this... why not measure a different way?

This is what they were using in Wuhan (reportedly). At measure 3 you become a clinical diagnosis, subject to the judgment of the physician, obviously. At SARS-CoV-2 positive you become presumptive positive, and on lab confirm you become a confirmed case. The idea is for the CDC to track the diagnosis as soft number, vs clinical confirmation as the rigorous one.

Ok, goodness, you are going to out-respond me because my attention is divided/limited right now, but that (communist) flow chart is not a good idea, imho.

I'll just let some other folks chime in but it isn't great to presume positive based on the very non-specific metrics identified. Sure, if we had an unlimited supply of hydroxychloroquine/remdesivir etc. it might make sense to triage folks based on a CT scan and other indications in some places, but...that's not our situation. (We certainly also don't have an unlimited availability to a CT scan, btw, as per above. And CT scans aren't cheap...)

It might be a more productive conversation if you were actually responding to what I was saying instead of presuming I'm attacking President Trump or blaming people.

I'm not suggesting we equate a clinical diagnosis with a presumptive positive test or conflate either of those numbers with a lab confirmed test. Or that we triage based on a CT scan.

I'm also not suggesting we arbitrarily start giving people prescriptions based on the flow chart.

Doctors will clinically diagnose a patient and start treatment (including meds) based on their own judgment, not a flow chart. We trust them enough to make the diagnosis already. I'm just wondering why we wouldn't track the number of patients who have been diagnosed with corona virus by an MD. You could make this diagnosis (slightly more) rigorous by providing docs with some reporting guidelines.

How many patients today are being treated for COVID19 without a lab confirmed test or a lab positive right now? With a 3-4 day turn time, I'm betting a lot.

It wouldn't surprise me if this was being monitored, even if it isn't being made public.

k2aggie07 said:

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China allowed it in their stats due to testing capacity constraints (just like we're having here). The WHO team noted that they were doing CT scans extremely rapidly because they were using them for screening / diagnostic purposes.

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China has portable CT scanner able to do do a scan in minutes. Someone correct me if I'm wrong, but we cannot do the same in the US.

Seems like the most straight-forward measure would be where we stand on non-bacterial pneumonia cases requiring hospitalization. We are actually hitting the end of the respiratory virus season (yes, I know it happens all year, but peak months of November through March can be as much as 2-3x the volume of other months). This is relevant from an overall health of the population perspective as well as an ICU and ventilator utilization perspective. It also cuts out the noise around comorbidities.

The higher number of cases might seem bad at first glance, but actually it could potentially show a much lower mortality rate. If our current mortality rate, including cases not yet tested, was something like 0.3% or lower, then we'd be having a different conversation in this country than the one where we are having at 1.3%.

It would help messaging a bunch of it he local pols could say "we've diagnosed x new cases today, we tested y new cases, confirmed count is now z".

Especially since we're diagnosing cases that we're not testing, and there's a 3-4 day lag between test and confirm.

k2aggie07 said:

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Even if we don't tally them in the super-duper official stats, why wouldn't the CDC allow doctors to submit clinical diagnoses of COVID19? You'd figure xray or CT scan of bilateral interstitial pneumonia plus doctor's judgment would be good enough right now.

Sidesteps the whole test kit issue.

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CT is just not specific enough to use as a screening tool for COVID-19. I've seen a couple of cases of interstitial pneumonia in the last 2 weeks and thought to myself, "could be COVID". Sure enough both were tested based on imaging and clinical criteria and both negative for coronavirus. A negative CT scan also does not rule out COVID-19.

From the American College of Radiology:

(Updated March 22, 2020) As an interim measure, until more widespread COVID-19 testing is available, some medical practices are requesting chest CT to inform decisions on whether to test a patient for COVID-19, admit a patient or provide other treatment. The ACR strongly urges caution in taking this approach. A normal chest CT does not mean a person does not have COVID-19 infection - and an abnormal CT is not specific for COVID-19 diagnosis. A normal CT should not dissuade a patient from being quarantined or provided other clinically indicated treatment when otherwise medically appropriate. Clearly, locally constrained resources may be a factor in such decision making.


Hope this helps.

Thanks doc! That is very interesting.